They did a pretty good job at representing both sides of the coin. I will concentrate on some flawed reasoning coming from the antivaccination crowd. Now let me make clear that I am not a doctor, and have no specialized knowledge about vaccines. These are my thoughts based on what I have been able to gather by reading various sources. If I say something which is not correct please do point it out in the comments section.

I chose not to vaccinate my children after one child developed a severe reaction to the vaccination. Also, I believe we are inviting a destruction to our immune system by disallowing it to fight the natural childhood diseases that come along.

It is a big mistake to say that vaccines “dont allow the immune system to fight the natural diseases”. The whole point of a vaccine is exactly the opposite, to get the immune system to fight off a weakened version of the germ causing the disease, so that it would know what to do when the living germ gets into the body. The parent also committs the natuaralistic fallacy, by somehow implying that “natural diseases” should be allowed to exist. I don’t understand that. HIV, Cancer, Heart Disease, Strokes all of these are natural diseases. In fact I am not even sure what an unnatural disease is..

My 3 year old has some of his shots but not all. As parents we decided to go slowly on vaccinating him as opposed to flooding his body full of unnatural agents. When we heard about the measles outbreak we did get him a measles shot. I don’t have any second thought to our process with vaccines.

There goes the natural fallacy again. Vaccines are referred to as “unnatural agents”. What the hell is that? A chemical that does not exist in nature? I find it really hard to believe that there is anything in vaccines that cannot be found in nature. Furthermore, vaccinating after there is an outbreak is not only inefficient, but irresponsible too. There does not need to be an outbreak in order for your kid to become sick. This parent needs to have lots of second thoughts on the issue. Next time the kid may not be so lucky and get sick before there is a big outbreak. I mean how does this parent think an outbreak occurs anyway? It is an outbreak when large numbers of people get sick. And that large number of people could very well include her kid. Bad, bad reasoning.

Many of us who choose not to vaccinate are not totally opposed to vaccinations and the benefits they can provide, but rather we are just asking for a safer vaccination schedule and safer vaccines. I hope that one day it will be possible to protect our children from disease without the fear of a life long disability like Autism. I choose not to vaccinate my twins because if they got chicken pox, measles, or even pertussis it would not be nearly as devestating as Autism has been for our son or our family.

There is nothing, nothing, to relate vaccines with autism. Absolutely nothing. This person’s child was diagnozed with autism after receving his 15 month shots. Well, I have a 1 year old and I am personally aware of the amount of vaccines they get before 15 months. If vaccines do infact cause autism, why is it that it shows up so late? Why didn’t it show up earlier? Furthermore, in early stages vaccines are given at 3 or 6 month intervals. Regardless when a kid is diagnosed with autism, it is bound to be within a short period of time after getting some shot. What about the claim that it’s better if kids get other diseases rather than autism? Well given that vaccines have not been shown to cause autism, that is basically saying that in order to feel like we’re doing something to prevent a disease we don’t know how to prevent, we will forgo protection on the ones we do know how to prevent. Weird reasoning no? I won’t even go into a whole what’s worse autism or the other ones. Another parent shows clearly how bad the other diseases can be.

I’m old enough to remember life without vaccines for measles and chicken pox and I suffered the consequences of the diseases. Measles, both kinds, Red and German, ruined my eyesight. Chicken pox left me with permanent scars on my face and body. I was so sick with the Red Measles that I also came down with pneumonia and almost died at the age of seven.

Let’s move on to the next comment.

I have chosen not to vaccinate my daughter. My stepson has autism which could put my daughter at a greater risk for contracting it. Currently she has come down with Rubella (german measles) she had a high fever for 5 days, following a rash from head to toe. Was she sick? Yes, and miserable. However, would I choose two weeks of that over a lifetime of Autism. YES!!!! With the rate of Autism on the rise 1 in 150. And no known cause of it, why wouldn’t a parent whose child is at a greater risk decide to not put those poison’s into their child’s body?

Ok so what this person is saying is that “there is no known cause of autism” and at the same time saying tht if she vaccinated her daughter, she would have gotten autism, thus vaccines are a cause of autism. A bit contradictory, wouldn’t you say?

My children did have some vaccines BUT after my soon to be 3yr old regressed after a series of vaccines last yr I have stopped vaccinating them as I truly believe that all the poison in those shots caused his autism. I also wonder why unvaccinated children can be blamed for vaccinated people being at risk! IF the vaccines are supposed to be safe and protet them then those who are vaccinated should have NO reason to fear the unvaccinated children!!!

See, it is exactly the lack of basic understanding that makes people affraid. They are litterally scared because they lack knowledge. Vaccines are not 100% effective, in fact some wear out and you need booster shots. Because they are not 100% effective, there is a small chance that you could get sick, even if you get the shot. However, if everyone got shot, there would be much less of a chance for the germ to survive in the “herd” and thus risk infecting that small portion of unlucky vaccinated people. Long answer short, herd immunity is affected as more and more people don’t get vaccinated. To illustrate that point:

While I vaccinated my child with everything the government advises, my child still got whooping cough because so many parents don’t (or won’t) vaccinate their children. The diseases mutate and become stronger and healthy children who’s parents have taken every precaution get extremely sick. My child was horribly sick for an entire summer and no matter how many times we went to the doctor they couldn’t figure out what was causing her cough because doctor’s don’t think to look for illnesses that children have been vaccinated against. Only after my child had become better did we learn that there had been an outbreak of whooping cough in our area. Shame on the parents that think they are doing their children a favor by not immunizing them. Not only are you endangering your childs life you are endangering every person that your child comes in contact with!

Let’s keep going:

Vaccinating children is stupid and reprehensible. We have absolutely no way of knowing what goes into vaccines. As recently as ten years ago they contained mercury derivatives which could cause ppermanent harm to anyone taking them. I inquired upon a visit to the county health department and was shocked and horrified upon ten minutes of searching to see it openly admitted (albeit in the smallest fine print) that these rumors were correct. If the government doesn’t mind putting mercury in your children who knows what else the CDC may consider an ‘acceptable risk.’

Ok, there goes the unavoidable conspiracy idiot. He’s not even a parent apparently, so I don’t know what his comment is doing in an article about “parents”. Too juicy to be passed over by the journalist I guess.

We choose not to vaccinate our children. Childhood diseases are not getting better, they are just changing. Vaccinations may happen to lower the original diseases, but they have opened up a whole new world of childhood diseases. We choose to keep our children safe and clean. If they happen to get sick then we know the Doctors are very capable of helping them through their sickness. We are certain there are risks with vaccinations and we are not willing to put our children through that. It is wrong for a government or any other group of people to tell us what is best for our children. This is not neglect or abuse. We are sincerely interested in the health and well being of our children. We are not ignorant or illiterate.

No, not ignorant or illetarate, but misguided and scared probably. Childhood diseases are not getting any better? Really? Where are their statistics coming from? Whose research about childhood diseases before and after vaccines are they relying on? Very weird statement indeed. Sounds like a sentence that had been copied and pasted from so woo master’s website without a second thought to it. They choose to keep their children “safe” by denying them the protection of vaccines? Something is not quite right there. So the doctors are very capable of helping the kids when they do get sick, but apparently they ar notcapable enough to prevent the diseases thay can treat. Dubious reasoning no? And how does it make sense to say that it is wrong for any group of people to tell parent’s what’s best for their children. By any group do they mean experts such as the able doctors they refer to? How is it wrong for a group of experts in a field to advise a group of non-experts about the right choice?

My son has not been vaccinated for several years. He had convulsions and quit breathing after every vaccination and now suffers minor learning diabilities. It scares me, because I certainly dont want to lose him to measles, or hepatitus… or the vaccine.

I feel for this parent. It is obvious that her son has some sort of allergic reaction to the vaccines, and the parent is rightly worried about the missed protection these vaccines could offer her son. I hope this never becomes an issue for their family.

To close it off there’s nothing I could say that would sum it up better than what another parent had to say:

Parents of kindergarteners today never had to deal with childhood disease as a certainty. In the ’50’s & ’60’s, it was so certain kids would get measles, mumps and chicken pox, that parents would make all their kids sleep with the first one who contracted a disease, so to “get it over with”. Young parents weren’t around to see children in iron lungs, and leg braces, wobbling on crutches regularly. They have never had to almost lose their hearing or suffer such after-effect from mumps or measles. They have never had to worry that they might contract measles while pregnant (because they most likely have been vaccinated for measles). They have no idea of what can be the new reality if fewer and fewer children are vaccinated. Young parents of today have benefited from the availability of vaccines and the requirements that school districts and state health boards had previously made. I shudder to think that our society cannot seem to learn from history, and since every generation seems to know it all better than any previous, we are doomed to repeat our history as well.

Let’s hope she’s not right about the repeating history part. Let’s really hope.

Another interesting case has hit the news. The decision of the California Supreme Court hinged on interpretation of state non-discrimination law. I’m not a lawyer, but I do know a bit about medicine and medical ethics. Regardless of law, this doctor’s behavior was wrong. The details are a little sketchy, but an unmarried lesbian woman was denied fertility treatments by a California doctor because the treatment conflicted with the doctor’s faith.

Conflicted with the doctor’s faith. There’s the rub.

This is a particularly perverse form of prostelitizing. It doesn’t involve having coffee with an acquaintance and teaching them the Word. It involves a vulnerable individual, who comes to a qualified professional for help, and is turned away because of “improper” living and thinking. In this case, it is disputed whether the patient was denied care because of being gay or because of being unmarried. It doesn’t really matter. Either reason for discrimination is wrong. What matters is that the doctor felt that treating the patient would violate her own religious beliefs.

–Unmarried persons and gays and lesbians have interests in having and rearing children.
— There is no persuasive evidence that children raised by single parents or by gays and lesbians are harmed or disadvantaged by that fact alone.
–Programs should treat all requests for assisted reproduction equally without regard to marital status or sexual orientation.

When you decide to become a doctor, you immerse yourself to the neck in ethical problems for the rest of your career. Patients make bad decisions. Other doctors make bad decisions. Ethically grey conundrums pop up on a daily basis. Standards set by professional organizations help to sort some of these out, but not always. The “most wrong” decision in an ethical debate is the cop-out. For a physician to deny a patient care based on their own beliefs is a cop-out, and is a coercive use of their paternalistic powers. This decision doesn’t just deny them your personal services. It may cause permanent psychological harm to the patient. And that’s not what doctoring is all about.

Over the last few decades, the nature of medical knowledge has changed significantly. Before the revolution in evidence-based medicine, clinical medicine was practiced as more of an art (in the “artisan” sense). Individuals were treated empirically with a strong knowledge of medical biology, and the guidance of “The Giants”, or particularly skilled and respected practitioners. While the opinions of skilled practitioners is still valued, EBM adds a new value—one of “show me the evidence”.

Evidence-based medicine refers to the entire practice of gathering and applying medical knowledge. This includes evaluating diagnostic tests (e.g. how well does an CT scan diagnose pulmonary embolism?) and evaluating treatments (e.g. which anticoagulant is most effective, which one is safer, how long should you treat, etc.) There will always be some questions that are untestable, and some for which no testing is needed, and practices for which evidence is sketchy.

In corresponding with a friend recently, I started thinking about how we look at the quality of medical evidence, and how we can communicate this to the lay public.

Let’s take, for example, cholesterol.

It has been found over the years that there is a strong association between elevated cholesterol and coronary artery disease. Through many studies, it was found that LDL cholesterol is a useful marker of cardiac risk due to elevated cholesterol. Finally, it was found that lowering LDL cholesterol, especially with statin drugs, dramatically reduces heart disease risk and mortality.

That’s the facts. But what are they based on? How strong is the evidence?

Before the report gets to any recommendations, it presents a table explaining how evidence used in the report is graded. First is the type of evidence (from randomized controlled trials down to clinical experience) then is the quality (from “very strong evidence” to “strong trend”).

That “A1″ at the end gives an idea what kind of evidence we’re working with. In this case the statement is based on RCTs and there very strong evidence to support it.

Evidence-based medicine is about evidence. Sometimes that evidence is quite good, sometimes it isn’t: the quality of evidence is something we take into consideration when treating patients.

This is in stark contrast to so-called alternative medicine. Alternative medicine never discusses quality of evidence. The quality is usually, however, quite poor, relying on patient and physician anecdotes, uncontrolled “trials”, and fantasy.

Making use of EBM doesn’t have to be difficult. You don’t have to be able to interpret every chi-squared analysis, you don’t have to calculate every number needed to treat. You just have to be able to read the basic literature in your field, look up recommendations, and know how strong they are.

Anyone practitioner who ignores evidence-based medicine is not practicing the best of modern medicine. Anyone who treats disease without understanding the difference between evidence-based practice and non-evidence-based practice should hand you a Quack Miranda Warning when you walk in the door.

Look, whether you like it or not, you can’t live forever. I bring this up because there is always a new book or new add purporting to have “the answer” to long life and good health, which never includes modern, evidence-based medicine. Still, perhaps some of these books contains good advice. Or not. Let me explain.

First let me disabuse some of you of the thought that doctors don’t “do” nutrition and life-style advice. In fact, we do. And as attractive as the idea seems, life-style modification will never be the answer to all of (or even most of) our medical problems. Leaving aside the fact that many people cannot make permanent and beneficial changes in their life-styles, there are many other reasons. Human health and disease is complex. Most diseases are multifactorial. For example, type II diabetes is caused by a combination of genetic factors and diet. Some patients can remain off medication using diet and exercise. Some cannot, as even with a good body mass index, good diet, and good exercise habits, their blood sugars are still out of control. Another example is hypertension. Dietary sodium reduction has been shown to reduce blood pressure, but many patients will not have significant enough improvements in blood pressure through diet and exercise alone.

Another reasons that lifestyle changes aren’t the whole answer is that sometimes drugs provide benefit that diet and exercise cannot. For example, beta blockers reduce blood pressure, but they also prevent sudden and premature death in certain groups of patients (i.e. those with significant heart failure), independent of the effect on blood pressure.

Finally, many purely genetic diseases are not amenable to lifestyle modification. No amount of diet and exercise will fix cystic fibrosis or congential adrenal hyperplasia.

Living healthy is important, but there is no miracle to maintaining health and treating disease. No one book is going to help you live forever. Lifestyle modification is not the answer to every medical question, no matter how much we all wish it were.

The discussion we’ve had since Friday regarding the Bush administration’s latest foray into theocracy brought up some interesting points. We discussed implications of the draft regulations including likely limitations on access to safe and effective birth control. But there is another issue here that disturbs me greatly.

Last week we talked a little bit about medical ethics. I’m not an Ethicist (Mike! Are you reading?), but I am a “practical ethicist”, as are all health care providers. How do ethics inform the discussion of what care we can or cannot provide?

First, let’s take the gloves off for a moment. What is a “pharmacist”?

A pharmacist is a trained professional with an expert knowledge of medications. In the retail setting, their primary role is to dispense medications, but their actual role is far greater. Pharmacists check patients’ records for drug interactions, counsel patients on how to properly store and take medications, and communicate with doctors regarding potential problems with prescriptions. Pharmacists are not, in most settings, the patient’s clinician, and do not have the same type of (ethical) relationship to their customers as doctors do with their patients. They are, at the simplest level, technicians and scientists who help maintain the safety and integrity of patients’ medications. It is a great responsibility—one small mistake on the part of a pharmacist can kill, and one small mistake caught by a pharmacist can save a life.

When a pharmacist receives a prescription from a physician that they believe may pose a threat to a patient, they call the doctor. For example, if I were to write a prescription for levothyroxine 125mg daily, the pharmacist would call me up to see if I meant micrograms rather than milligrams (125 mg is a helluva lot of this drug). If I tell the pharmacist to shut up and dispense the damned drug as written, they might refuse to pending further research, discussion, etc. This often happens with opiates. I may prescribe a cancer patient a very large dose of morphine and the pharmacist will call me to confirm. I’ll explain that they have been on this dose and tolerated it well, and the pharmacist will likely be satisfied that I know what I’m doing.

A pharmacist that receives a properly written prescription for a medication that any reasonable doctor would consider safe may not ethically refuse to fill it. The doctor and patient are the ones who make the decision on what meds are proper. In this case the pharmacists only remaining job, after checking for allergies and drug interactions, is to fill the legal prescription. If they don’t wish to do that, they should be fired, just as the check-out clerk would be fired for refusing to ring up a candy bar (and no, it doesn’t matter how fat the customer is). It has come up frequently that pharmacists sometimes refuse to fill birth control pills. This is unconscionable. The doctor and patient have a clinical relationship; the pharmacist in this instance is an intermediary, and could theoretically be replace by a sophisticated vending machine. Hmmm….

__________

The relationship between physician and patient is a bit more complicated. There is an asymmetry in the power relationship—anything the doctor says and does is potentially coercive. The doctor and the patient both count on this asymmetry—a patient goes to the doctor for advice, a doctor hopes their position of authority will help persuade the patient to do what is necessary (more on this issue of autonomy vs. paternalism here).

If a doctor tells a patient that smoking is dangerous, the patient is likely to believe them and will treat the words differently than if they had come from someone else. The same goes for a doctor’s opinions. If I tell my patient that I love Obama and that voting for McCain would ruin the American health care system, I’m probably using my influence in a bit of a shady manner. If a young woman comes to me wishing to terminate a pregnancy, and I tell her it is tantamount to killing a child, it means something very different to her than if she sees it on a billboard. If I oppose abortion, and feel I wish to be a “conscientious objector”, to share that with the patient is no longer an act of conscience, but an act of coercion. It is a desertion of my duty as a physician. I have patients who are Jehovah’s Witnesses. I give them very detailed information about the medical (not moral) consequences of their beliefs, but I stop there.

Doctors are activists—activists for the rights and needs of our patients, to which we subsume our own values to a great extent. This is one of the great challenges of medicine, and if you’re not up to the task, it’s time to get out.

On the one side are scientists who have been unable to find any causal link between the symptoms of autism and the vaccine preservative thimerosal, which in the body breaks down into ethylmercury, the culprit du jour for autism’s cause. On the other side are parents who noticed that shortly after having their children vaccinated autistic symptoms began to appear. These anecdotal associations are so powerful that they cause people to ignore contrary evidence: ethylmercury is expelled from the body quickly (unlike its chemical cousin methylmercury) and therefore cannot accumulate in the brain long enough to cause damage. And in any case, autism continues to be diagnosed in children born after thimerosal was removed from most vaccines in 1999; today trace amounts exist in only a few.

I’m so angry I can barely type coherently. I have very strong feelings about abortion, but I believe it is possible to respectfully disagree about the ethical issues involved. I have an obstetrics colleague who does not perform abortions, but refers patients needing this service to others. That’s the ethical way for a doctor to oppose abortion—don’t do it, don’t prosteletize, refer out. My personal feeling is a woman has the right to control her body and all that dwells within, but I can see why others would disagree.

All that being said, if you chose a profession that will, by its very nature create an insoluble ethical conundrum, you need to get a new job. Pharmacists who refuse to dispense birth control when given a lawfully written prescription should be fired immediately and consider a change in careers.

The Religious Right is trying to protect these types of “acts of conscience.” Traditional passive resistance in the model of Thoreau and King emphasized the breaking of unjust laws and the acceptance of any punishment that goes with it. The religious right in this country is not content with this model—they would prefer to allow for acts of conscience without consequences. In this vein, the Church Amendment was passed. This amendment protects professionals who are trying to impose their values on others by mandating that health care providers who receive federal funds not require providers to provide services that to which they morally object. This has not been widely enforced apparently, because a draft is circulating at the Department of Health and Human Services that would step up enforcement, and broaden the services to which people could object, even protecting them if they refuse to refer to an alternate provider. This document terribly flawed for a number of reasons.

This draft misunderstands fundamentally the nature of health professionals. We serve patients, not ourselves. The draft document equates providers who refuse to provide or refer for services with conscientious objectors in time of war. This is patently ridiculous. We have a volunteer military. When we had draft, it was possible for someone who would normally have nothing to do with war be forced into a moral dilemma. The way out was CO status, which would allow pacifists to serve without taking life. Service wasn’t a choice—killing was.

I chose to be a physician, knowing full well that medicine is fraught with moral ambiguities. I could have opened a coffee shop instead. Professional organizations recognize the primacy of our patients’ needs over our own—our obligations are not to our own morals but to our patients. It’s part of our ethical code.

The HHS draft makes a mockery of this. It quotes a study that states that many physicians feel that they are obliged to present all options to patients regardless of their personal objections. The draft points out that this may be contrary to law. This may be true, but the fact is that WE ARE ETHICALLY OBLIGED TO PRESENT ALL MEDICALLY APPROPRIATE OPTIONS. No law changes these ethics, and in fact, it might be argued that any laws that directly conflict with our ethical obligations to our patients are immoral and require us to speak and act in opposition to these laws.

The draft attempts to create a conflict where none exists. Health care providers do not need their morals to be protected from discrimination. If we object to standard medical practices, we can find a position where our morals aren’t challenged (but that’s hard to find in medicine).

The draft seeks to more strongly enforce the Church Amendments. To justify this invasion of the doctor-patient relationship, it makes some very dubious claims. One is that Plan B, the pill that prevents embryonic implantation, is an “abortifacient”. More on this shortly.

Another claim is that forcing doctors to subsume their beliefs to their professional obligations will cause a shortage of health care professionals. What unmitigated bullshit.

But then comes the really sinister bit. They wish to redefine abortion for the purposes of the statutes. In order to do that they invoke a Zogby poll of American values, and two medical dictionaries. They mention the British and American Medical Associations’ definition as pregnancy occurring after implantation, and then toss away the professional definition for two dictionaries and a poll. They also propose to determine what constitutes abortion by the individual’s conscience “within the bounds of reason”. In other words, any health care professional can call anything an abortion and be legally protected from providing medically and ethically appropriate care. Let me quote the report:

“Abortion” means any of the various procedures—including the prescription, dispensing, and administration of any drug or the performance of any procedure or any other action—that results in the terminatino of the life of a human being in utero between conception and natural birth, whether before or after implantation.

Your federal government is giving doctors, nurses, and pharmacists the freedom to deny you anything they don’t like, including most forms of birth control. Heard of Griswold v. Connecticut? Forget about it. The government has decided that with regard to health care, the Establishment Clause is irrelevant, and the Free Exercise clause is more important than the rights of patients. You should be very afraid for your personal freedoms.

The theocrats who are attempting to make this law are too cowardly to give up their comforts for their beliefs. Rather than engaging in passive resistance, they wish to legislate their religion. If this becomes the law of the land, expect to see some real passive resistance from the health care community. Keep your eyes open, and vote wisely.

Here’s the thumbnail: an alarmist report was released by the UP Cancer Institute’s Center for Environmental Oncology. It was apparently targeted at the university community, and stated that despite lack of current evidence, the community should worry about cell phones this instant.

On the official website, no author is listed. But authority is invoked…sort of…

The Case for Precaution in the Use of Cell Phones: Advice from University of Pittsburgh Cancer Institute Based on Advice from an International Expert Panel

Advice from UPCI based on advice from a international panel…a panel whose names are deceptively listed at the bottom of the report, as if they have endorsed it.

So who wrote and released this irresponsible, panic-infused report?

A driving force behind the memo was Devra Lee Davis, the director of the university’s center for environmental oncology. “The question is do you want to play Russian roulette with your brain,” she said in an interview from her cell phone while using the hands-free speaker phone as recommended. “I don’t know that cell phones are dangerous. But I don’t know that they are safe.”

Hey, I don’t know for an absolute certainty that my popcorn won’t spontaneously combust, but I’m not yelling fire either.

From NPR:
“She said 20 different groups have endorsed the advice the Pittsburgh cancer institute gave…”

Read carefully…these groups didn’t endorse the report…they endorsed advice similar to that given in the report. The irresponsibility is tumesceing rapidly.

The warning is also apparently based on unpublished data from a poorly done study, but that won’t deter the cell phone panic squad:

Really at the heart of my concern is that we shouldn’t wait for a definitive study to come out

Of course not. That would be too…scientific.

At least some of the students are smart:

“I think if they gave me specific numbers and specific information and it was scary enough, I would be concerned,” [the student] said, planning to call her mother again in a matter of minutes. “Without specific numbers, it’s too vague to get me worked up.”

I can’t think of a comparable event to this. Will the University distance itself from this rogue cellphone savior?

E-mail Policy excerpt

E-mails sent to the authors of this blog may be used as material for post entries at Skepfeeds, but the person’s contact e-mail address and name will not be made public on the blog, unless the e-mails take on a harassing nature in which case the full fury of the Skepfeeds community shall be unleashed upon the offender.